Provider Demographics
NPI:1508162645
Name:THOMPSON, SARA NICOLE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SARA
Middle Name:NICOLE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:NICOLE
Other - Last Name:NILIUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-308-2660
Mailing Address - Fax:
Practice Address - Street 1:1421 MALABAR RD NE STE 200
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2559
Practice Address - Country:US
Practice Address - Phone:321-308-2660
Practice Address - Fax:321-984-9303
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108278363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid
FLPA9108278OtherLICENSE
FLMEDICAREOtherMEDICARE
FLKQ667OtherFL MEDICARE